Category: Fraud

Employees can have a misconception that workers’ compensation fraud is not a big deal. But, it’s a felony.

How can you shift your company culture and employee mindset to reduce your insurance premiums and workers’ compensation costs? Combat fraud with training.

In 2011, a self-insured company brought in an SIU director, (a colleague and client of ours), to help with their out-of-control claim costs. The SIU director implemented a nationwide anti-fraud training program that focused on safety and fraud prevention.

Since 2011, the number of employees for this company grew by 88%, yet claims costs went down by 95% and claims were reduced by 34%. This was accomplished by a company with high risk employees in food service, security, and janitorial occupations.

The proof is in the pudding. Experts in the risk management industry agree that providing anti-fraud and comprehensive safety training to self-insured companies has consistently proven to reduce claims and reduce workers’ compensation costs.

Prevention

Once a suspicious claim is filed, you are going to spend money. Training as a prevention tool is a great way for you to keep fraudulent claims from being filed or abused in the first place.

A comprehensive safety program informs your entire staff the laws and repercussions of fraudulent activity. Training gives them the tools to identify and report perpetrators before it is too late. Awareness and preparation are the best deterrents of fraud.

Awareness

Saving money starts with the awareness of one employee. This awareness redirects their ambitions from personal benefit to company success.

Make sure their understanding of fraud is clear and that they know how to properly report any suspicious activity. Explain to them how a co-worker, who may be out of work, costs the company and themselves more money and time in the long run.

Train upper level management so they know what is going on with their employees and can quickly mitigate losses. Make sure supervisors are proactive and thorough if they suspect fraud.

Standard of Performance

When employees know that their colleagues and supervisors are vigilant, they’ll be more inclined to work efficiently. With awareness, the employee’s interest will steer towards the productivity and welfare of the company. This mentality within the workforce will reduce fraud significantly.

Re-Create Company Culture

Instill in your employees that fraud will not be tolerated. Your employees need to know that fraud is illegal and that it increases the company’s insurance premiums, which negatively affects every employee.

Pay-n-Chase Costs More

Sometimes, it may seem easier to pay for the claim. We know, there is often so much on our plate that adding another task and expense seems unfathomable. But, pursuing a suspicious claim costs much more than preventing one.

Invest in a training program and appreciate the dramatic reduction in your claims cost and case volume. According to the Association of Certified Fraud Examiners, the approximate loss of money by businesses to fraud amounts to $3.5 trillion dollars per year. Investments like comprehensive safety training are simple fixes to the daunting price of fraud.

Red Flags are alerts based on common patterns or behaviors found among fraudulent workers’ compensation claims. These Red Flags help you spot early on possible exaggerated or falsified information. Once you notice one or multiple Red Flags in a claim, further investigation is needed. But, before you call your private investigation firm (P.I.), what do these suspicious claims show?

By familiarizing yourself with these Red Flags you can quickly identify scam patterns and spot potential workers’ comp fraud.

10 Red Flags to Identify Workers’ Compensation Fraud

1) History of Claims

The employee has filed multiple claims over the years with multiple employers. If the claimant knows the game, and has success getting away with past workers’ comp fraud, he or she is more than willing to exaggerate his or her claim again.

2) Suspicious Providers

Claimants use medical providers or legal consultants who have a history and reputation of handling fraud claims. Proof of fraudulent behavior becomes increasingly difficult when a claimant is able to secure an advocate in one of these professions.

You may start to notice the same doctors or attorneys used by groups of claimants.

3) No Witnesses

If a claimant falls at work and no one is around to see it, did the injury happen?

No witnesses for an employee's injury claim is a Red Flag. If the claimant’s ‘word’ is the only proof of the incident occurring, then he may be exaggerating or falsifying his story.

4) Conflicting or Varying Descriptions

Similar to ‘No Witnesses,’ the claimant provides a description of her injury that conflicts or varies with her medical history, conflicts or varies with the witness statements, or conflicts with the injury report.

In these cases, inconsistencies can range from the date and time of the injury to the location of the injury.

5) Treatment Refusal

Refusing to receive treatment for an injury is certainly suspicious behavior. Often an employee simply doesn’t want to work and has no desire to seek treatment or promote healing.

6) Frequent Changes

Frequent changes in physicians and attorneys may indicate that the claimant is attempting to search for an attorney or physician who will support his case.

The claimant may also change addresses frequently in order to make it difficult to contact them and to observe his or her activities.

An immediate investigation, starting with witness statements, is a great way to get the story documented early. When changes occur, you can compare them to an initial report.

7) Late Reporting

The claimant delays an injury claim. In this case, the claimant may try to convince you that after the alleged incident she felt fine, but after some time passed, her injury progressed. Witness accounts of the incident combined with surveillance of the claimant’s activities are suggested for this Red Flag.

8) Monday or Friday Incidents

Similar to late reporting of the injury, be wary if the alleged injury occurred on a Monday morning or a Friday afternoon. This Red Flag may suggest the injury was a result of a non-work related accident over the weekend, or may suggest the claimant desires an “extended” weekend.

9) Claimant Grudge

The claimant may be reacting to a personnel action, a denied vacation, termination, or denied promotion. Suspicious claims are also filed when the claimant is about to retire. Essentially, the claimant has a grudge and is finding a way to extend his or her income, make a silent protest, or has lost his will to work.

10) Claimant is Hard to Reach

Despite multiple efforts, the claimant cannot be found or reached at home. When the claimant is allegedly recovering at a certain location (such as his or her home) and cannot be contacted, it raises a Red Flag. Surveillance can discover if the claimant is playing cat and mouse, may be working, or even on vacation.

Red Flags are a great first step to determining the legitimacy of a claim. These alerts help you quickly identify claims that need to be investigated. Paying a claimant who is committing fraud costs more than an investigation ever will.